Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

TandemandOvoidsprocedure
StructuralDesign
Traditionally,gynecologicintracavitaryirradiationhasbeendeliveredusing
lowdoserate(LDR)brachytherapy.However,todayhighdoserate(HDR)brachytherapyis
alsocommonpracticefortreatmentofgynecologicmalignancies.Aunitmadeupofatandem
andapairofovoidsisthecommonlyusedafterloadingapplicatorinthetreatmentoftheuterine
cervix.TheFletcherandSuittandemandovoidsystemisrigidbutflexibleenoughtobeused
1
formostpatients.
Atandemisanintrauterineapplicator.Itisdesignedtofitinsidetheuterine

canalandextendoutofthevagina.Thetandemisahollowtube,whichhasadiameterof6mm
1,2
andis27cmlong.
Oneendofthetubeissealedinordertoblocksourcesfromfallingout
2
insidethepatient.Acervicalstopfitsintothetandemtopreventperforatingtheuterus.
In

general,tandemsareconstructedofstainlesssteel.Theyareapproximately12inchesinlength
withanouterdiameterofapproximatelyinch.Theinternaldiameterisdesignedtoallowthe
1
plastictubeholdingthesourcetobeinsertedwithoutmeetingresistance.
Ingeneral,12low

doserate(LDR)sourcesareloadedintothetandem.Thenumberofsourcesdependsonthe
2
lengthofthepatientsuterus.
Whiletandemsareeitherstraightorofvariousdegreesof

angulation,15,30,45,or60degrees,itismostcommontotreatapatientusinganangled
tandem.Thepurposeoftheangleofthetandemistodrawtheuterustoacentrallocationwithin
thepelvis,thusawayfromthesigmoidcolon,aswellas,theanteriorrectalwall.Theanglealso
2
accountsfortheforwardtiltoftheuterus.
Whenatandemiscorrectlyinsertedintheuterine

canal,akeelissecuredtothetandem.Whenthetandemisfullyinsertedintotheuterus,thekeel
islocatedatthecervicalos.Thekeelservesasamarkeroftheexternalcervicaloswhen
referencepointsaredeterminedfordosecalculations.Thekeelalsokeepsthetandemfrom
accidentallybeingpushedfartherintotheuterus,whichcouldcauseperforation.
Theovoidsareovalshapedandapproximately20mmindiameterand30mminlength.
Theyarehollowandlikethetandemmadeofstainlesssteel.Theovoidsareattachedtoahollow
handlethroughwhichtheradioactivesourceisinserted.The2ovoidsareinsertedintotheright
andleftfornicesofthevagina.Onceinserted,the2ovoidsareheldtogetherviaascrew,which
allowstheovoidstomovelaterallywhenthehandlesatthedistalendarepressedtogether.
1

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Thehandleprotrudesoutsideofthevagina.Oncethetandemandovoidsareinsertedand
positioned,thephysicianpacksthevaginawithsterilegauzetoholdtheapplicatorinplace
1
duringthedurationoftheimplant.

IntracavitarybrachytherapyalsousesHighdoserate(HDR)applicators.HDR
applicatorsaresimilartothoseusedforLDRprocedures.Itshouldbementionedthough,that
HDRapplicatorscanbeutilizedincomputedtomography(CT).Whiletheapplicatorscontain
metal,theartifactfiltermaybeusedsinceheterogeneitycorrectionsarenottakenintoaccountin
3
brachytherapytreatmentplanning.

4
Figure1.Tandems.

4
Figure2.Ovoids.

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

5
Figure3.Anteriorviewoftandemandovoidsplacement.

5
Figure4.Sagittalviewoftandemandovoidsplacement.

HowImplantisInserted
PerDr.ChristineFisherMDMPH(April2016),agynecologyradiationoncologist,atthe
UniversityofColoradoHospitaltheprocedurewasdescribedasfollows.AnHDRtandemand
ovoidinsertiontakesplaceintheoperatingroom(OR)underlightanesthesia.Thepatientisina
relaxedsleepwheretheywontremembertheprocedurebutcanberousedifmade
uncomfortable.UsingbetadineanexternalandinternalprepisdonebeforeaFoleycatheteris
insertedintothebladderandtheballoonisfilledwithcontrast.Thebladderisthenfilledwith
sterilesalinetopushanysmallbowelsuperiorandawayfromthetandemandovoidsystem.The
catheterisclampedtoholdtheliquidinplace,duetothecontinuedintravenoushydrationsome
fluidisletoutofthebladderbeforeleavingtheORtoensurepatientcomfort.Theattendingand
theresidentbothperformamanualexamtofeelfortheextentofthetumorandtheshape.The

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

doctorsneedtoknowwherethetumorextendsinalldirectionsandthesizeandintegrityofthe
vaginalfornices.Witharectalexamthepresenceoftumorextensionintotherectumcanbe
palpated.Oncetheexamisdone,thedecisioncanbemaderegardingwhichangleoftandemand
sizeofovoidtouse.Dr.Fishersaidthe30degreestandemfitsmostpatientsandmediumisthe
usualovoidsize.
Undertransabdominalultrasoundtheuterusissoundedwithaflexibledevicethathas
millimeterandcentimeterincrementsprinted.Soundingreferstomeasuringofthedepthofthe
uterusfromthecervicalOStothetopoftheuterus.Thissolidstrawlikedeviceispushedallthe
waytothetopoftheuterusandthedepthisrecorded.Thenthetandemisslideintothevaginal
cavity,throughthecervicalopeningandallthewaytothetopoftheuterus.35mmissubtracted
fromthesoundeddepthandthatisthedepthtowhichthetandemisinsertedoruntiltheuterus
tents.Allofwhichisvisualizedunderultrasoundtopreventperforatingtheuterus,which
accordingtheattendingiseasytododependentontheextentofthetumor.Ifforceisrequiredto
pusharoundthetumor,careneedstobetakentoavoidforcingthesteeltandemstraightthrough
thetopoftheuterus.Thisisavoidedwithcarefulstudyoftheultrasoundasthetandemis
inserted.Theflangeorkeelisthensecuredontothetandemtoholdthetandemintotheuterusat
therequireddepthatthecervicalOS.Theovoidsarethenpositionedandallthehardware
extendsoutsideofthevagina.Thesystemissecuredtogetherwithascrew.
Theresidentthenpacksthevaginalcavitywithgauzeribbonembeddedwithradiopaque
markers.Thispackinghasatwofoldpurposeposteriorlyitpushestherectumfurtherawayfrom
thetandemandovoidanditholdseverythinginplace.Thepackingisalsousedanteriorlyto
pushthebladderaway.Packingisanartbecauseitcanmovethesystemintoimproperalignment
whichwillbeanatomicallyunfavorable.Forexample,thecurvatureoftheuterusshouldbe
anteriorfallingsuperiorlyoverthebladderandnotposterior.Inthecasewheretheuterus
naturallyflopsbackwards,theattendingwillinsertthetandemandthenrotateittoforcethe
angleanteriorandsuperior.Oncethepackingandsystemarestabilized,thepatientisawakened
andtransportedtothedepartmentforthesimulation.

PatientSimulation

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Simulationforthetandemandovoidsbrachytherapyprocedureisunconventionalwhen
comparedtoexternalbeamradiationtherapy(EBRT).WhileEBRTperformsthesimulation
priortothetreatment,brachytherapysimulationisdoneafterthetandemandovoidshavebeen
6
placedinsidethepatient.
AseriesofCTscansorxraysareusedtoverifycorrectsource

positioninganddosecalculation.Oncethetandemandovoidshavebeenlocalized,themedical
physicistandphysicianplantheappropriateamountoftimerequiredtodeliverprescribeddose
tothetarget.DosetopointsonCTscansarecalculated(seeDoseCalculationsSection).There
7
havebeenquestionsaboutwhetherCTsimulationisnecessaryfortandemandovoidplacement.

Patientstreatedwithtandemandovoidswithoutasimulationreceivedagreatersurfacedoseto
therectum,bladderandvagina,thepercentincreaseswere35%,30%and45%respectively.This
supportsthateachpatientshouldhaveasimulationpriortobrachytherapyplacement.

8
Figure3
.
TandemandOvoidsseenonxrays(A)andCT(B).

A)

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

B)

LDR/HDRforTreatment
Applicatorsusedinintracavitarybrachytherapy,canbeutilizedwithbothLDR(lowdose
rate)andHDR(highdoserate)brachytherapymethodsfortreatinggynecologicmalignancies.
TraditionallyLDRbrachytherapywasthestandardtreatmenttechniqueforgynecologic
malignanciesbutHDRmethodsarebecomingincreasinglypopularformany
reasons/advantages.ALDRsourceusedforintracavitarybrachytherapyisCesium137from
Radium226thatwasoriginallyusedinthepast.Cesium137asaclinicalsourceisapure
gammarayemitterandcomesinstainlesssteelencapsulatedneedlesandtubes.Thegammarays
9
emittedfromCesium137havealmostthesamepenetratingpowerasRadium226.
AHDR

sourceusedforintracavitarybrachytherapytodayisoftenIridium192.Iridium192emitsbeta
particlesthataretakenup/eliminatedbythestainlesssteelcapsuleandclinicallyusefulgamma
rayssuchsourceisoftenmanufacturedintheshapeofseedsandcancomeinnylonribbons
containingtheseseedsinwhichtheribbonsarethenplacedinsidehollowplastictubingto
9
delivertreatment.
LDRcorrelatestoaprescriptiondoserateontheorderof.52cGy/minand

HDRisclassifiedtodeliver20cGy/minorhigher.TheprincipleadvantageofHDRoverLDR
istheprocedurecanbeperformedasanoutpatientprocedureaswellasgreatercontroloverdose
10
distribution.
OtheradvantagesofHDRversusLDRbrachytherapyincludeseaseoftreatment,

minimalradiationexposuretopersonnel,andconsistentplusreproducibleapplicatorpositioning.
6

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Asidefromalltheadvantages,HDRcancausemoredamagewhenitcomestotoxicity,
surroundingORdoselevels,andlateeffects
foragivenleveloftumorcontrol.
However,
the
possibilityofoptimizingdosedistributionandthelesserchanceofapplicatordisplacementseem
tooutweighthesedisadvantages.DisadvantageswitnessedwithLDRbrachytherapyincludes
increasedexposureofradiationtopersonnel/staff,theneedforhospitalizationofuptoaweek,
theriskofanesthesia,bedimmobilizationthatcanleadtothromboembolism,discomfortof
vaginalpackingandapplicatorsduringbedimmobilization,anddisplacementofthe
11
applicators.
BecausethepatientneedstoliemotionlessforthedurationofLDRtreatment,it

couldleadtobloodclotsorpressureulcersfromlayinginthesamepositionforalongperiodof
time.ForthesescarydisadvantagesseenwithLDRbrachytherapy,itiseasytoseewhyHDR
brachytherapyshouldbeconsidered,andisbecomingastandardtreatmentstrategyforpatients
withcervicalcancer.
11
AliteraturereviewwasperformedbyViani,Manta,Stefano,Fendi
toevaluateHDR

intracavitarybrachytherapyversusLDRintracavitarybrachytherapy,whenbothmethodshave
beenaround/utilizedforyears.MortalityratesdidnotshowadifferencebetweenLDRandHDR
researcharmsandHDRdidnotshowanydifferenceindosetosurroundingORstructures
11
comparedwithLDR.
Althoughallstudiesprovedtoachievesimilarresults,HDRwasshownto

havejustslightlyincreasednumbersoflocalrecurrence,mortality,anddosetosurroundingOR.
Sincethelocalcontrolandsurvivalrateswereprovenverysimilarinthemetaanalysisof
literaturecurrentlypublished,HDRisagoodalternativetoLDRintracavitarybrachytherapyand
offersthemanyaforementionedadvantages.Althoughsomeoftheliteraturereviewproved
promisingtreatmentresultsandfavorableoutcomes,thisliteraturereviewalsofoundthatpoorer
outcomeaswellasoverallsurvivalanddiseasefreesurvivalwaslowerintheHDRgroupfor
stageIIIcervicalcancerpatients.

DoseFractionationSchemes
Thepracticeofusinghighdoserate(HDR)brachytherapytotreatgynecologicalcancers
byuseoftandemandovoidsallowsforamuchhigherdosetothetargetarea.Afterspeaking
withtheradiationoncologistatmycurrentfacility,Dr.OscarGarcia(April2016),heinformed

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

methatheprescribesHDRbrachytherapyoncethepatienthasreceivedtheirfullcourseof
externalbeamradiationof4500cGytotheprimaryfields,plusanadditional3fractionboostof
540cGyforatotaldoseof5040cGyforexternalbeamtreatments.HDRdosesatourcenterare
typicallyachievedin5fractionsthatconsistof500cGyandarerecommendedtobeginnolater
than2weeksfollowingtheterminationoftheexternalbeamradiationtreatments.Thepatient
willhavetwotreatmentsperweek,allowingforatotaldoseofupto7540cGy,ifthedosetothe
rectumandbladderarenotcompromisedbeyondthelimits.
Generallyspeaking,patientswithintactcervicalcancertraditionallyreceivelowdoserate
12
(LDR)brachytherapyin1or2separatetreatmentsessions.
Thesetreatmentsshouldalsotake

placebetweenthesecondandfourthweekfollowingtheircompletionofexternalbeamradiation
therapy.Ontheotherhand,patientswithintactcervicalcancerreceivingHDR,arenormally
prescribed46fractionsdependingontheextentofthediseaseanddosestosurrounding
structures.HDRshouldbeadministeredinthesecasesnolaterthan8weeksaftertheirinitial
externalbeamtreatment.
Thedesiredgoalisthatthepatientshouldreceiveatotaldoseof8085Gyforsmall
12
cervicaltumors,and8590Gyforlargetumors.
Toachievethisgoal,itisimportanttonote

thatthedosetothebladderandrectummuststaybelow80%ofthetotaldosetopointA,orless
than7580Gytothebladder,andlessthan7075Gytotherectum.
PointAisareferencepointdevelopedfortheManchestersystemsothatthe
12
brachytherapydosemaybeprescribedtothispointforpatientswithintactcervicalcancer.

PointBisanotherreferencepointthatwasusedintheManchestersystemthatcorrelatedwith
thelocationoftheobturatorlymphnodes,howeveritisnowrecommendedbytheAmerican
BrachytherapySociety(ABS)touseasidewalldosepointratherthanPointB,dueto
inconsistenciesinpatientanatomy.PointsM,T,andHareadditionaldosepointsthatcanbe
used,howeverthesearesubjecttochangeatdifferentcentersofcare.
Belowyouwillfindseveraltables(14)publishedforthevariousfractionationschemes
12
availabletopatientsreceivingLDRorHDR.
Thesetablesvarydependingonextentofthe

disease,locationofthetumor,andwhetherthepatientwillreceiveLDRorHDR.
Table1:CervicalcancerLDRguidelines

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Table2:PostopHDRguidelinesforuterinecancer

Table3:InoperableuterinecancerHDRguidelines

Table4:CervicalcancerHDRguidelines

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

DoseCalculationSystems
Therehavebeenmanydosecalculationsystemsdevelopedinthelastcentury,butthe
onesthatarethemostnotablehistoricalsystemaretheStockholmsystem,Parissystem,andthe
1
Manchestersystem(PatersonParker).
Eachsystemvariesbytheirrulesofimplantationofthe
1
brachytherapyapplicator,doseuniformitystandards,andreferencedosespecification.
More

recentlytherehavebeenadvancementsindoseandvolumespecificationswiththeICRU38
reportandtheABSsystem.

TheStockholmsystemusedapplicatorsthatdidnotadjust,butwereeasytouse(less

10
uncertainty).
Theapplicatorwasmadeupofarubbertandemandagoldorsilvervaginal
10
applicatorbox.
Thesystemusedthree22hourinsertionsandunequalloadingtheinthe
10
226
226
applicator.
Theprescriptionswere3090mg
Rainuterusand6080mg
Rainthevagina
226
foratotalof65007100mg
Ra.Thissystemhasahighdoserateandhighrateofsideeffects

andcomplicationsforthepatient.
TheParissystemonlyusedoneinsertion,butforlengthof510days.Theamountof
226

1,10
Rausedintheuterusandvaginawereequalandthetotalmghourswerefixed.
Evenly

226
distributingthe
Rainthetandemresultedinanonuniformdosedistributiontowardsthe
1
centerofthetandem.
Morerecently,Ir192havebeenusedwiththeParissystemismgRaeq

10

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

values.TheParissystemgaverisetosomeoftherecommendationsfoundintheICRU38
guidelines.
TheManchestersystemwasalsoknownasthePatersonParkerandisthemostfrequently
1,10
usedsystem.
Thedosespecificationparametersforthissystemincludedthetotalnumberof

mgsofRadiumortheequivalentinallthesources,theplacementofthesesourcesmustbeinthe
1
tandemandovoids,andthetotaltreatmenttime.
Theprescriptionpointusedinthissystemis
10
knownasPointA.
In1938,PointAwasdefinedtobe2cmsuperiorand2cmlateralofthe
10
centeroftheuterinecanalwheretheuterinevesselscrossedtheureter.
PointAwasalso

believedtobetheinitialpointofradiationnecrosis.PointBwasoriginallydefinedasthe
10
locationoftheobturatornodesandwaslocated3cmlaterallytoPointA.
However,PointsA
10
andBwereeventuallyredefinedinthe1950s.
ThereviseddefinitionofPointAis2cm

superiortothelowerendofthetandemalongthetandemand2cmlateraltothecentralcanal.
TherevisedPointBdefinitionis2cmsuperiortotheexternalcervicalosand5cmlateralalong
1
thebodyplane.
Duetotherevisions,PointsAandBmaynotbeonthesameplaneasPointAis

moredependentontheangleofthetandem.PointAisusefulforreportingdose,butispoorly
relatedtothetumorlocationandvarieswithapplicatorplacement.Typically,PointAwas
1
limitedtoreceiving30%ofthetotaldoserateofthewholetandemandovoid.

11

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

Figure1:PointAandBwhenapplicatorperpendiculartobodyplane.Theimageonrightshowsthelocation
ofPointAwhentandemistilted.ThisisbecausetheredefinitionofPointAismoredependentontheTandem
1
asopposedtopatientanatomy.

ICRU38developedasystemforreportingdoseforgynecologicalbrachytherapy.The

systemisbasedonthetotalairkermastrengthofallthesourcesintheimplantmultipliedbythe
10
numberofhourstheapplicatorwasinthepatient.
ICRU38definesthedoseasisodosesurface
10
thatsurroundthetargetvolumewhichknownasthereferencevolume.
Thereferencevolumeis

definedtobethe60GyisodosesurfaceincludesanyEBRTcontributionandisbasedonthe
10
Parissystem.
ICRU38hasdeterminedotherpointsofinterestthatareimportantfortheorgans

atriskthebladderpoint,rectalpoint,andpelvicwallpoints.Thebladderandrectumpoints
10
mustbelimitedto70%oftheprescribeddose.

TheAmericanBrachytherapySociety(ABS)alsodevelopedguidelinesthatincludedose

calculationinformation.TheABSsystemdefinestreatmentvolumesinadifferentwaythanthe
ICRU38reportbyaddinginCTVsthataretoincludespecificanatomicstructuresbasedon
high,intermediate,andlowrisk.TheorgansatriskfortheABSarethesameastheICRU38
10
recommendationsinregardstobladderandrectalpoints.
TheprescriptionpointsaretheHigh

riskCTVorPointA.Nowthatbrachytherapycalculationsarebecomingmorecomputerized,the
10
ABShasintroducedguidelinesforLDRandPDR.
PointAshouldreceive8090Gy,Sigmoid

colonandrectumshouldbe7075Gy,andbladderlessthan90GyincludingtheEBRT
10
contribution.

Resources:
nd
1. BentelGC.
RadiationTherapyPlanning.
2
ed.NewYorkNY:McGrawHill1995.

2. Lenards,N.
LDRIntracavitaryImplants
.[SoftChalk].LaCrosse,WI:Medical
DosimetryProgram2016.
3. Lenards,N.
HDRIntracavitaryBrachytherapy
.[SoftChalk].LaCrosse,WI:Medical
DosimetryProgram2016.

12

Group2:Tamara,Sharan,Shands,Kristine,Glenda,Kevin

4.
DwyerK.FletchersuitTandemandOvoid.McLarenCancerCenterFlint,MI.Taken
April262016.
5. MillerR.AboutCancerWeb
site.
http://www.aboutcancer.com/intracavitary_radiation_treatments.htm.
AccessedApril27,
2016.
6. MassachusettsGeneralHospitalCancerCenter.
WhatYouNeedToKnowAboutTandem
AndOvoidImplantsForCervicalCancer
.1sted.Boston,MA:TheGeneralHospital
Corporation2015.Availableat:
http://www.massgeneral.org/radiationoncology/assets/pdfs/Tandem_and_Ovoid_Implants
_for_Cervical_Cancer_MGH_2015.pdf.AccessedApril26,2016.
7. JonesN,RankinJ,GaffneyD.Issimulationnecessaryforeachhighdoseratetandem
andovoidinsertionincarcinomaofthecervix?.
Brachytherapy
.20043(3):120124.
doi:10.1016/j.brachy.2004.07.001.
8. TypesofImageGuidedBrachytherapy|UCLARadiationOncology|Radiation
OncologyUCLA.
Radoncuclaedu
.2016.Availableat:
http://radonc.ucla.edu/imageguidedbrachytherapytypes.AccessedApril26,2016.
9.
KhanFM,GibbonsJP.
ThePhysicsofRadiationTherapy.
5th

ed.Philadelphia,PA:
LippincottWilliamsandWilkins,aWoltersKluwerbusiness2014.
10.
LenardsN,SchmidtD,BernerP.
Brachytherapyimplantsintroduction.
[SoftChalk].La
Crosse,Wi:UWLMedicalDosimetryProgram2016.
11.
VianiGA,MantaGB,StefanoEJ,FendiL.Brachytherapyforcervixcancer:lowdose
rateorhighdoseratebrachytherapyametaanalysisofclinicaltrials.
JExpClin
CancerRes.
200928(47).
DOI:10.1186/175699662847.
http://jeccr.biomedcentral.com/articles/10.1186/175699662847
12. KhanFM,GerbiBJ.
TreatmentPlanninginRadiationOncology
.3rded.Philadelphia,
PA:LippincottWilliams&Wilkins2012.

13